Administrative Policy Statement WEST VIRGINIA MARKETPLACE PLAN Contents of Policy
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Administrative Policy Statement WEST VIRGINIA MARKETPLACE PLAN Policy Name Policy Number Date Effective Site of Care for Drug Administration PAD-0023-WV-MPP 03/01/2020 Policy Type Medical ADMINISTRATIVE Pharmacy Reimbursement Administrative Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. Contents of Policy ADMINISTRATIVE POLICY STATEMENT ..................................................................................1 TABLE OF CONTENTS ..............................................................................................................1 A. SUBJECT .........................................................................................................................2 B. BACKGROUND ................................................................................................................2 C. DEFINITIONS...................................................................................................................2 D. POLICY ............................................................................................................................2 E. CONDITIONS OF COVERAGE ........................................................................................5 F. RELATED POLICIES/RULES ...........................................................................................5 G. REVIEW/REVISION HISTORY ........................................................................................5 H. REFERENCES .................................................................................................................5 Pharmacy - Site of Care for Drug Administration West Virginia Marketplace Plan PAD-0023-WV-MPP Effective Date: 03/01/2020 A. SUBJECT This policy outlines required criteria for administration of drugs at the hospital outpatient setting as the site of service and directs members to the most cost-effective site of care. It also outlines medications to which this policy applies. B. BACKGROUND The CareSource Pharmacy Policy Statement is a guideline for determining site of care coverage for selected drugs. It is used as a tool to be interpreted in conjunction with the member's specific benefit plan. The intent of CareSource Site of Care for Drug Administration policy is to outline the requirements for coverage for the outpatient hospital drug administration. C. DEFINITIONS Site of Care: Choice for physical location of infusion administration. Sites of Care include hospital inpatient, hospital outpatient, provider’s office, ambulatory infusion center, or home- based setting. D. POLICY This policy does not apply to the first administration of a drug. The first dose can be administered at any facility of the physician’s choice. All subsequent doses will be subject to the CareSource Site of Care for Drug Administration policy which requires the use of a non-hospital outpatient facility or home care setting. Note: Therapy that consists of a single administration of a drug is considered the first administration. I. CareSource considers outpatient hospital facility-based intravenous medication infusion necessary if member meets one of the following: A. Member is initiating therapy for the first time or therapy reinitiated after more than 6 months; B. Member has documentation of previously severe or potentially life-threatening adverse event (e.g., anaphylaxis, seizures, renal failure, etc.) during or following infusion of the prescribed medication, and the adverse event cannot be managed through pre-medication in the home or office setting; C. Member is medically unstable for administration of the therapy due to one of the following: 1. history of cardiopulmonary conditions 2. difficulty establishing and maintaining vascular access 3. physical or cognitive impairments that can cause an unnecessary health risk 4. unstable renal function; D. Medication requested is not available for administration at one of the following: 1. non-hospital outpatient facility 2. physician’s office 3. home-based setting 4. ambulatory infusion center; II. CareSource requires subsequent doses of the following medications to be administered in a non-hospital outpatient facility, provider’s office, ambulatory infusion center or homesetting: THERAPY DESCRIPTION CODE BRAND NAME Alpha-1 Deficiency J0256 Aralast NP, Prolastin, Zemaira Alpha-1 Deficiency J0257 Glassia Blood Cell Deficiency J0881 Aranesp Blood Cell Deficiency J0885 Epogen, Procrit 2 Pharmacy - Site of Care for Drug Administration West Virginia Marketplace Plan PAD-0023-WV-MPP Effective Date: 03/01/2020 THERAPY DESCRIPTION CODE BRAND NAME Blood Cell Deficiency J1447 Granix Blood Cell Deficiency J2820 Leukine Blood Cell Deficiency J2562 Mozobil Blood Cell Deficiency J2505 Neulasta Blood Cell Deficiency J1442 Neupogen Enzyme Deficiencies J1931 Aldurazyme Enzyme Deficiencies J1786 Cerezyme Endocrine Disorders J0584 Crysvita Enzyme Deficiencies J1743 Elaprase Enzyme Deficiencies J3060 Elelyso Enzyme Deficiencies J0180 Fabrazyme Enzyme Deficiencies J0221 Lumizyme Enzyme Deficiencies J3397 Mepsevii Enzyme Deficiencies J1458 Naglazyme Enzyme Deficiencies J1322 Vimizim Enzyme Deficiencies J3385 VPRIV Growth Deficiency J1930 Somatuline Depot Hemophila/Bleeding Disorders J7192 Advate Hemophila/Bleeding Disorders J7207 Adynovate Hemophila/Bleeding Disorders J7210 Afstyla Hemophila/Bleeding Disorders J7186 Alphanate Hemophila/Bleeding Disorders J7193 Alphanine Hemophila/Bleeding Disorders J7201 Alprolix Hemophila/Bleeding Disorders J7194 Bebulin Hemophila/Bleeding Disorders J7195 Benefix Hemophila/Bleeding Disorders J2724 Ceprotin Hemophila/Bleeding Disorders J7180 Corifact Hemophila/Bleeding Disorders J2597 DDAVP Hemophila/Bleeding Disorders J7205 Eloctate Hemophila/Bleeding Disorders J7198 Feiba NF Hemophila/Bleeding Disorders J7170 Hemlibra Hemophila/Bleeding Disorders J7192 Helixate FS Hemophila/Bleeding Disorders J7190 Hemofil M Hemophila/Bleeding Disorders J7187 Humate-P Hemophila/Bleeding Disorders J7202 Idelvion Hemophila/Bleeding Disorders J7198 Ixinity Hemophila/Bleeding Disorders J7199 Jivi Hemophila/Bleeding Disorders J7190 Koate-DVI Hemophila/Bleeding Disorders J7192 Kogenate Hemophila/Bleeding Disorders J7193 Mononine Hemophila/Bleeding Disorders J7182 Novoeight Hemophila/Bleeding Disorders J7189 Novoseven Hemophila/Bleeding Disorders J7209 Nuwiq Hemophila/Bleeding Disorders J7194 Profilinine Hemophila/Bleeding Disorders J7192 Recombinate Hemophila/Bleeding Disorders J7178 RiaSTAP Hemophila/Bleeding Disorders J7200 Rixubis 3 Pharmacy - Site of Care for Drug Administration West Virginia Marketplace Plan PAD-0023-WV-MPP Effective Date: 03/01/2020 THERAPY DESCRIPTION CODE BRAND NAME Hemophila/Bleeding Disorders J7181 Tretten Hemophila/Bleeding Disorders J7183 Wilate Hemophila/Bleeding Disorders J7185 Xyntha Hereditary Angioedema J0597 Berinert Hereditary Angioedema J0598 Cinryze Hereditary Angioedema J1744 Firazyr Hereditary Angioedema J0599 Haegarda Hereditary Angioedema J1290 Kalbitor Hereditary Angioedema J0596 Ruconest HIV J1746 Trogarzo Immune Deficiency J1566 Carimune NF Immune Deficiency J1555 Cuvitru Immune Deficiency J1569 Gammagard Liquid Immune Deficiency J1666 Gammagard S-D Immune Deficiency J1561 Gammaked Immune Deficiency J1557 Gammaplex Immune Deficiency J1561 Gamunex-C Immune Deficiency J1559 Hizentra Immune Deficiency J1575 HyQvia Immune Deficiency J1568 Octagam Immune Deficiency J1459 Privigen Inflammatory Conditions J3262 Actemra Inflammatory Conditions J0490 Benlysta Inflammatory Conditions J0717 Cimzia Inflammatory Conditions J3380 Entyvio Inflammatory Conditions J0638 Ilaris Inflammatory Conditions Q5103 Inflectra Inflammatory Conditions J0129 Orencia Inflammatory Conditions J1745 Remicade Inflammatory Conditions Q5104 Renflexis Inflammatory Conditions J1602 Simponi Aria Inflammatory Conditions J3358 Stelara IV Miscellaneous Diseases J0364 Apokyn Miscellaneous Diseases J3590 Myalept Miscellaneous Diseases J1300 Soliris Miscellaneous Diseases J1628 Tremfya Miscellaneous Diseases J3590 Ultomiris